Introduction

Definition of Turf Toe

Turf toe, also known as metatarsophalangeal joint sprain and it is an injury that affects the joint located in the big toe. It is caused by overextending your toe, from lifting your heel whilst the toe remains on the ground. This then causes the soft tissues and the ligaments to tear and stretch, causing a toe sprain. Turf toe is more common in athletes, those who dance, and in women who wear high heels for longer periods of time.¹

Anatomy and Biomechanics

Overview of the first the metatarsophalangeal (MTP) joint

In the big toe, there are 2 joints present. The largest one is called metatarsophalangeal (MTP) joint. It supports the big toe in giving stability and movement. The MTP joint is surrounded by different structures that hold its position and prevent the joint from dislocating. The different structures as a whole are called the plantar complex, which include:²

• Plantar plate - found under the MTP joint, and prevents the big toe from bending too far upwards
• Flexor hallucis brevis - a tendon that is found under the metatarsal bone and attaches to the proximal phalanx, providing strength and stability to the big toe
• Collateral ligaments - found on each side. Connect the phalanx bone to the metatarsal bone, helping in preventing the toe from going far side -to-side
• Sesamoids - two small bones that surround the flexor hallucis tendon. It also helps to stabilise the MTP joint by bearing the weight placed on the forefoot

Mechanism of injury leading to Turf Toe

The first MTP joint, which is located at the base of the big toe, acts as both a hinge and sliding joint but has limited stability because of the shallow structure. Stability relies on surrounding ligaments, tendons, and the joint capsule. The plantar plate, the strongest stabilizer, is a thickened part of the joint capsule that connects to nearby ligaments and tendons, ensuring proper function and support.^1,3

Clinical History

Symptoms

Turf toe symptoms range from mild to severe and will also depend on person-to-person. When you first experience a turf toe, you may hear a “pop” sound when the injury happens. But, when turf toe symptoms from repetitive injuries appear, it can get worse over time. The symptoms of turf toe include:³

• Pain
• Tenderness
• Swelling
• Bruising
• Joint may feel loose
• Limited range of motion
• Stiffness

Activity History

To better understand how and why you may be experiencing pain and tenderness, physical activity is also taken into consideration. The doctor may ask you if you have had any recent athletic participation, such as football, or dancing, and the type of footwear you were wearing during the time of injury. 

You may also be asked about any prior injuries to your foot, and if you have any chronic conditions, such as arthritis, that could have an effect.^2,3

Physical Examination

During the physical exam, your doctor will ask you about several questions and will have a look at the injury:⁴

• Inspection - the doctor will look at swelling, redness, and bruising at the first MTP joint
• Palpation: there should also be tenderness over the joint capsule and plantar plate and to detect the joint instability
• Range of motion  -  the doctor will evaluate how your toe performs and you will generally feel pain with active flexion in the joint
• Stability Tests - to check for stability,  Lachman or drawer tests are done for MTP joint and assessment of ligament integrity
• Functional Assessment - the doctor will also check your ability to walk or bear weight and will do a gait analysis for compensatory patterns

Diagnostic Imaging

To help confirm your diagnosis, the doctor may order other tests, including:

• Radiography -  X-rays can help to rule out fractures or sesamoid injuries and help to assess the joint alignment and joint spacing
• MRI - this helps to provide a detailed visual of soft tissue damage of the plantar plate  and ligaments
• Ultrasound - can help in giving a real-time evaluation of ligament and tendon injuries
• CT Scan - mainly used in more severe cases needing a detailed imaging^2,4

Differential Diagnosis

The differential diagnosis of turf toe includes:

• Fracture
• Bunions
• Gout
• hallux rigidus

Infection

• Reverse turf toe
• Sesamoiditis

Key Considerations in Diagnosis

Severity grading of injury^5,6

To help plan the treatment for your turf toe, the doctors may grade the injuries from grade 1 to 3, meaning from mild to severe.

• Grade 1 - the plantar complex is stretched, causing only pinpoint tenderness and some swelling
• Grade 2 - partial tearing of the plantar complex, causing more tenderness and swelling with less movement of the toe 
• Grade 3 - complete tearing of the plantar complex, with severe tenderness, pain, bruising and swelling. Difficulty in moving the big toe

Impact of delayed diagnosis^5,6

It is important to ensure you get your turf toe checked at the right moment because, if it is not checked and diagnosed at the right time, you may suffer from grade 3 injuries, which will require surgery to treat it and will also require a long duration of time for your foot to heal and be back to normal.  

Conclusion

A turf toe injury can be uncomfortable at first and may need care to ensure it does not get any worse. It is important to make sure you get an appropriate diagnosis, to make sure you have adequate treatment. If you feel pain in your toe during physical activities, take a break. Do not ignore pain and try to push through, it will only make it worse. Ensure you see a doctor that can help you in treating the injuries.